Summary about " Religion, Culture, and Nursing "

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Religion, Culture, and Nursing Chapter 13

Patricia A. Hanson and Margaret M. Andrews

Dimensions of Religion

Religion is complex and multifaceted in both form and function. Religious faith and the institutions derived from that faith become a central focus in meeting the human needs of those who believe. The majority of faith traditions address the issues of illness and wellness, of disease and healing, of caring and curing (Ebersole, Hess, & Luggan, 2008; Fogel & Rivera, 2010; Leonard & Carlson, 2010).

Religious Factors

Influencing Human Behavior First, it is necessary to identify specific religious factors that may influence human behavior. No single religious factor operates in isolation, but rather exists in combination with other religious factors and the person’s ethnic, racial, and cultural background. When religion and ethnicity combine to influence a person, the term ethnoreligion is sometimes used. Examples of ethnoreligious groups include the Amish, Russian Jews, Lebanese Muslims, Italian, Irish, or Polish Catholics, Tibetan Buddhists, American Samoan Mormons, and so forth. Faulkner and DeJong (1966) have proposed five major dimensions of religion in their classic work on the subject: experiential, ritualistic, ideologic, intellectual, and consequential.

Experiential Dimension The experiential dimension recognizes that all religions have expectations of members and that the religious person will at some point in life achieve direct knowledge of ultimate reality or will experience religious emotion. Every religion recognizes this subjective religious experience as a sign of religiosity.

Ritualistic Dimension The ritualistic dimension pertains to religious practices expected of the followers and may include worship, prayer, participation in sacraments, and fasting

Ideologic Dimension The ideologic dimension refers to the set of beliefs to which its followers must adhere in order to call themselves members. Commitment to the group or movement as a social process results, and members experience a sense of belonging or affiliation.

Intellectual Dimension The intellectual dimension refers to specific sets of beliefs or explanations or to the cognitive structuring of meaning. Members are expected to be informed about the basic tenets of the religion and to be familiar with sacred writings or scriptures. The intellectual and the ideologic are closely related because acceptance of a dimension presupposes knowledge of it.

Consequential Dimension The consequential dimension refers to religiously defined standards of conduct and to prescriptions that specify what followers’ attitudes and behaviors should be as a consequence of their religion. The consequential dimension governs people’s relationships with others.

Religious Dimensions in Relation to Health and Illness Obviously, each religious dimension has a different significance when related to matters of health and illness. Different religious cultures may emphasize one of the five dimensions to the relative exclusion of the others. Similarly, individuals may develop their own priorities related to the dimension of religion. This affects the nurse providing care to clients with different religious beliefs in several ways. First, it is the nurse’s role to determine from the client, or from significant others, the dimension or combinations of dimensions that are important so that the client and nurse can have mutual goals and priorities. Second, it is important to determine what a given member of a specific religious affiliation believes to be important. The only way to do this is to ask either the client or, if the client is unable to communicate this information personally, a close family member. Third, the nurse’s information must be accurate. Making assumptions about clients’ religious belief systems on the basis of their cultural, ethnic, or even religious affiliation is imprudent and may lead to erroneous inferences. The following case example illustrates the importance of verifying assumptions with the client. Observing that a patient was wearing a Star of David on a chain around his neck and had been accompanied by a rabbi upon admission, a nurse inquired whether he would like to order a kosher diet. The patient replied, “Oh, no. I’m a Christian. My father is a rabbi, and I know it would upset him to find out that I have converted. Even though I’m 40 years old, I hide it from him. This has been going on for 15 years now.” The key point in this anecdote is that the nurse validated an assumption with the patient before acting. Furthermore, not all Jewish persons follow a kosher diet nor wear a Star of David. Fourth, even when individuals identify with a particular religion, they may accept the “official” beliefs and practices in varying degrees. It is not the nurse’s role to judge the religious virtues of clients but rather to understand those aspects related to religion that are important to the client and family members. When religious beliefs are translated into practice, they may be manipulated by individuals in certain situations to serve particular ends; that is, traditional beliefs and practices are altered. Thus, it

is possible for a Jewish person to eat pork or for a Catholic to take contraceptives to prevent pregnancy. Although some find it necessary to label such occurrences as exceptional or accidental, such a point of view tends to ignore the fact that change can and does occur within individuals and within groups. Homogeneity among members of any religion cannot be assumed. Perhaps the individual once embraced the beliefs and practices of the religion but has since changed his or her views, or perhaps the individual never accepted the religious beliefs completely in the first place. It is important for the nurse to be open to variations in religious beliefs and practices and to allow for the possibility of change. Individual choices frequently arise from new situations, changing values and mores, and exposure to new ideas and beliefs. Few people live in total social isolation, surrounded by only those with similar religious backgrounds. Fifth, ideal norms of conduct and actual behavior are not necessarily the same. The nurse is frequently faced with the challenge of understanding and helping clients cope with conflicting norms. Sometimes conflicting norms are manifested by guilt or by efforts to minimize or rationalize inconsistencies. Sometimes norms are vaguely formulated and filled with discrepancies that allow for a variety of interpretations. In religions having a lay organization and structure, moral decision making may be left to the individual without the assistance of members of a church hierarchy. In religions having a clerical hierarchy, moral positions may be more clearly formulated and articulated for members. Individuals retain their right to choose regardless of official church-related guidelines, suggestions, or even religious laws; however, the individual who chooses to violate the norms may experience the consequences of that violation, including social ostracism, public removal from membership rolls, or other forms of censure.

Social ostracism is especially problematic for those clients experiencing mental illness (Fayard, Harding, Murdoch, & Brunt, 2007; Fogel & Rivera, 2010; Matthew, 2008; Yurkovich & Lattergrass, 2008).

Religion and Spiritual Nursing Care

For many years, nursing has emphasized a holistic approach to care in which the needs of the total person are recognized. Most nursing textbooks emphasize the physical and psychosocial needs of clients rather than ways to address spiritual needs (Black, 2009; Ebersole et al., 2008; Fayard et al., 2007; Yurkovich & Lattergrass, 2008). Comparatively little has been written about guidelines for providing spiritual care to clients from diverse cultural backgrounds. Because nurses endeavor to provide holistic health care, addressing spiritual needs becomes essential. Religious concerns evolve from and respond to the mysteries of life and death, good and evil, and pain and suffering. Although the religions of the world offer various interpretations of these phenomena, most people seek a personal understanding and interpretation at some time in their lives. Ultimately, this personal search becomes a pursuit to discover a Supreme Being, God, gods, or some unifying truth that will give meaning, purpose, and integrity to existence (Ebersole et al., 2008; Keehl, 2009; Leonard & Carlson, 2010; Yurkovich & Lattergrass, 2008). Before spiritual care for culturally diverse clients is discussed, an important distinction needs to be made between religion and spirituality. Derived from Latin roots, the term religion means to tie or hold together, to secure, bind, or fasten. It refers to the establishment of a system of attitudes and beliefs. Religion refers to an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of a Supreme Being who is called by various names according to ethnoreligious traditions and beliefs. Among the important functions of religion is to create and nurture communal and individual spirituality. Religious activities often include reading scriptures or sacred writings (e.g., Qu’ran, Torah, Bible), praying, singing, and/or participating in individual or communal worship services (Leonard & Carlson, 2010). Spirituality is born out of each person’s unique life experience and his or her personal effort to find purpose and meaning in life. When people search for meaning or for a connection that transcends themselves, they are acting as spiritual beings. Spirituality exists in connections to others, the environment and the universe that lies beyond human experience. It refers to an ultimate reality. Present in all individuals, spirituality may be expressed as inner peace, and strength (Buck, 2006; Keehl, 2009; Narayanasamy, 2006; Yuen, 2007).

Spirituality encompasses “embracing, celebrating and voicing all the connections with the ultimate/mystery/divine, within me and beyond me, in experiences that give me meaning, purpose, direction, and values for my daily journey” (Leonard & Carlson, 2010; Spirituality in Healthcare Module, p. 1). While religion and spirituality have similarities and overlapping concepts, they are separate and distinct from one another (Black, 2009; Buck, 2006; Keehl, 2009). In general, religion addresses questions related to what is true and right and helps individuals determine where they belong in the scheme of their life’s journey. Spirituality emphasizes the pursuit of meaning, purpose, direction, and values.

Spiritual Nursing Care The goal of spiritual nursing care is to assist clients in integrating their own religious beliefs about a Supreme Being or a unifying truth into the ultimate reality that gives meaning to their lives. This is especially meaningful when people face a serious health challenges or crisis that precipitated the need for nursing care in the first place. Spiritual nursing care promotes clients’ physical and emotional health as well as their spiritual health. When providing care, the nurse must remember that the goal of spiritual intervention is not, and should not be, to impose his or her religious beliefs and convictions on the client (Amos, 2007; Gordon, 2006; Hubbell, Woodard, Barksdale-Brown, & Parker, 2006; Keehl, 2009; Tzeng & Yin, 2006; Yuen, 2007). Although spiritual needs are recognized by many nurses, spiritual care is often neglected. Among the reasons why nurses fail to provide spiritual care are the following: (1) they view religious and spiritual needs as a private matter concerning only an individual and his or her Creator; (2) they are uncomfortable about their own religious beliefs or deny having spiritual needs; (3) they lack knowledge about spirituality and the religious beliefs of others; (4) they mistake spiritual needs for psychosocial needs; and (5) they view meeting the spiritual needs of clients as a family or pastoral responsibility, not a nursing responsibility. Spiritual intervention is as appropriate as any other form of nursing intervention and recognizes that the balance of physical, psychosocial, and spiritual aspects of life is essential to overall good health. Nursing is an intimate profession, and nurses routinely inquire without hesitation about very personal matters such as hygiene and sexual habits. The spiritual realm also requires a personal, intimate type of nursing intervention (Black, 2009; Gordon, 2006; Hubbell et al., 2006; Keehl, 2009; Tzeng & Yin, 2006; White, 2007). In North America, efforts to integrate spiritual care and nursing have been under way for approximately four decades. In 1971 at the White House Conference on Aging, the spiritual dimension of care was defined as those aspects of individuals pertaining to their inner resources, especially their ultimate concern, the basic value around which all other values are focused, the central philosophy of life that guides their conduct, and the supernatural and nonmaterial dimensions of human nature.

The spiritual dimension encompasses the person’s need to find satisfactory answers to questions about the meaning of life, illness, or death (Ebersole et al., 2008; Jett & Touhy, 2010; Keehl, 2009; Moberg, 1971, 1981; Yuen, 2007). In 1978, the Third National Conference on the Classification of Nursing Diagnoses recognized the importance of spirituality by including “spiritual concerns,” “spiritual distress,” and “spiritual despair” in the list of approved diagnoses. Because of practical difficulties, these three categories were combined at the 1980 National Conference into one category, spiritual distress, which is defined as disruption in the life principle that pervades a person’s entire being and that integrates and transcends the person’s biologic and psychosocial nature. Moberg (1981) acknowledges the multidimensional nature of spiritual concerns and defines them as the human need to deal with sociocultural deprivations, anxieties and fears, death and dying, personality integration, self-image, personal dignity, social alienation, and philosophy of life.

Assessment of Ethnoreligious and Spiritual Issues

As discussed in Chapter 3, cultural assessment includes assessment of the relationship between religious and spiritual issues as they relate to the health care status of clients. In the integration of health care and religious/spiritual beliefs, the focus of nursing intervention is to help the client maintain his or her own beliefs in the face of a serious health challenge or crisis and to use those beliefs to strengthen the client’s coping patterns. If the religious beliefs are contributing to the overall health problem (e.g., guilt, remorse, expectations), you can conduct a spiritual assessment. To be therapeutic, begin by asking questions that clarify the problem, and nonjudgmentally support the client’s problem solving (Buck, 2006; Hubbell et al., 2006; Keehl, 2009; Yhlen & Ashton, 2006; Yuen, 2007; Yurkovick & Lattergrass, 2008). Box 13-1 Assessing Spiritual Needs in Clients from Various Ethnoreligious Backgrounds What do you notice about the client’s surroundings? • Does the person have religious objects, such as the Qur’an (Koran) Bible, prayer book, devotional literature, religious medals, rosary, or other type of beads, photographs of historic religious persons or contemporary religious leaders (e.g., Catholic Pope, Dalai Lama, or image of another religious figure), paintings of religious events or persons, religious sculptures, crucifixes, objects of religious significance at entrances to rooms (e.g., holy water founts, a mezuzah, or small parchment scroll inscribed with an excerpt from scripture), candles of religious significance (e.g., Paschal candle, menorah), shrine, or other item? • Does the person wear clothing that has religious significance (e.g., head covering, undergarment, uniform)? Does the hair style connote affiliation with a certain ethnoreligious group, for example, earlocks worn by Hasidic Jewish men? • Are get well greeting cards religious in nature or from a representative of the person’s church, mosque, temple, synagogue, or other religious congregation? How does the person act?

• Does the person appear to pray at certain times of the day or before meals? • Does the person make special dietary requests (e.g., kosher diet, vegetarian diet, or refrain from caffeine, pork or pork derivatives such as gelatin or marshmallows, shellfish, or other specific food items)? • Does the person read religious magazines or books? What does the person say? • Does the person talk about God (Allah, Buddha, Yahweh, Jehova), prayer, faith, or religious topics? • Does the person ask for a visit by a clergy member or other religious representative? • Does the person express anxiety or fear about pain, suffering, dying or death? How does the person relate to others? • Who visits? How does the person respond to visitors? • Does a priest, rabbi, minister, elder, or other religious representative visit? • Does the person ask the nursing staff to pray for or with him/her? • Does the person prefer to interact with others or to remain alone? Summarized in Box 13-1 are guidelines for assessing spiritual needs in clients from diverse cultural backgrounds (Figure 13-1).

Spiritual Nursing Care for Ill Children and Their Families

In a broad sense, any hospitalization or serious illness can be viewed as stressful and therefore has the potential to develop into a crisis. You may find that religion plays an especially significant role when a child is seriously ill and in circumstances that include dying, death, or bereavement. Illness during childhood may be an especially difficult clinical situation. Children as well as adults have spiritual needs that vary according to their developmental level and the relative importance of religion and spirituality in the lives of their primary providers of care. Parental perceptions about the illness of their child may be partially influenced by religious beliefs. For example, some parents may believe that a transgression against a religious law has caused a congenital anomaly in their offspring. Other parents may delay seeking medical care because they believe that prayer should be tried first. FIGURE 13-1 This statue commemorates the Roman Catholic Saint Martin De Porres. Born in Peru during the 16th century to a Spanish father and a Black mother, Martin De Porres studied medicine, which he later, as a member of the Dominican Order, put to use in helping the poor. He is honored by some Catholics as the patron saint of African Americans. When assessing the needs of clients from diverse backgrounds, nurses can observe for the presence of religious objects in the client’s home or yard (© Copyright M. Andrews).

The nurse should be respectful of parents’ preferences regarding the care of their child. When you believe that parental beliefs or practices threaten the child’s well-being and health, you are obligated to discuss the matter with the parents. It may be possible to reach a compromise in which parental beliefs are respected and necessary care is provided. On rare occasions, it may become a legal matter (Fogel & Rivera, 2010; Matthew, 2008). Religion may be a source of consolation and support to parents, especially those facing the unanswerable questions associated with lifethreatening illness in their children.

Spiritual Nursing Care for the Dying or Bereaved

Client and Family All people do not mourn alike. Mourning is a form of cultural behavior, and it is manifest in a multicultural society. Mourning customs help people cope with the loss of loved ones. Nurses inevitably focus on restoring health or on fostering environments in which the client returns to a previous state of health or adapts to physical, psychological, or emotional changes. However, one aspect of care that is often avoided or ignored, though every bit as crucial to clients and their families, is death and the accompanying dying and grieving processes. Death is indeed a universal experience, but one that is highly individual and personal. Although each person must ultimately face death alone, rarely does a person’s death fail to affect others. There are many rituals, serving many purposes, that people use to help them cope with death. These rituals are often determined by cultural and religious orientation. Situational factors, competing demands, and individual differences are also important in determining the dying, bereavement, and grieving behaviors that are considered socially acceptable (Amos, 2007).

The role of the nurse in dealing with dying clients and their families varies according to the needs and preferences of both the nurse and client, as well as the clinical setting in which the interaction occurs. By understanding some of the cultural and religious variations related to death, dying, and bereavement, the nurse can individualize the care given to clients and their families. Nurses are often with the client through various stages of the dying process and at the actual moment of death, particularly when death occurs in a hospital, nursing home, extended care facility, or hospice. The nurse often determines when and whom to call as the impending death draws near. Knowing the religious, cultural, and familial heritage of a particular client as well as his or her devotion to the associated traditions and practices may help the nurse determine whom to call when the need arises.

Religious Beliefs Associated with Dying

Universally, people want to die with dignity. Historically this was not a problem when individuals died at home in the presence of their friends and families. Now, when more and more people are dying in institutions (hospitals, hospices, and extended care facilities) ensuring dignity throughout the dying process is more complex. Once death is seen as a problem for professional management, the hospital displaces the home, and specialists with different kinds and degrees of expertise take over for the family (Amos, 2007). The way in which people commemorate death tells us much about their attitude and philosophy of life and death. Although it is beyond the scope of this book to explore the philosophic and psychological aspects of death in detail, some points will be made that relate to nursing care.

Preparation of the Body

A nurse may or may not actually participate in the rituals associated with death. When people die in the United States and Canada, they are usually transported to a mortuary, where the preparation for burial occurs. In many cultural groups, preparation of the body has traditionally been very important. Whereas members of many cultural groups have now adopted the practice of letting the mortician prepare the body, there are some, particularly new immigrants, who want to retain their native and/or religious customs. For example, for certain Asian immigrants it is customary for family and friends of the same sex to wash and prepare the body for burial or cremation. In other situations, the family or religious representatives may go to the funeral home to prepare the body for burial by dressing the person in special religious clothing. If a person dies in an institution, it is common for the nursing staff to “prepare” the body according to standard procedure. Depending on the ethnoreligious practices of the family, this may be objectionable—the family members may view this washing as an infringement on a special task that belongs to them alone. If the family is present, you should ask family members about their preference. If ritual washings will eventually take place at the mortuary, you may carry out the routine procedures and reassure the family that the mortician will comply with their requests, if that has in fact been verified. North American funeral customs have been the topic of lively discussion. The initial preparation of the body has been described in the following way: “After delivery to the undertaker, the corpse is in short order sprayed, sliced, pierced, pickled, trussed, trimmed, creamed, waxed, painted, rouged and neatly dressed…transformed from a common corpse into a beautiful memory picture. This process is known in the trades as embalming and restorative art, and is so universally employed in North America that the funeral director does it routinely without consulting the corpse’s family. He regards as eccentric those few who are hardy enough to suggest it might be dispensed with. Yet no law requires it, no religious doctrine commends it, nor is it dictated by considerations of health, sanitation or even personal daintiness. In no part of the world but in North America is it widely used. The purpose of embalming is to make the

corpse presentable for viewing in a suitably costly container, and here too the funeral director routinely without first consulting the family prepares the body for public display” (Kalish & Reynolds, 1981, p. 65). This extensive preparation and attempt to make the body look “alive,” “just as he used to,” or “just as if she were asleep” may reflect the fact that North Americans have come into contact with death and dying less than have other cultural groups

Funeral Practices

By their very nature, people are social beings who need to develop social attachments. When these social attachments are broken by death, people need to bring closure to the relationships. The funeral is an appropriate and socially acceptable time for the expression of sorrow and grief. Although there are some mores that dictate acceptable behaviors associated with the expression of grief, such as crying and sobbing, the wake and funeral are generally viewed as times when members of the living social network can observe and comfort the grieving survivors in their mourning, and say a last goodbye to the dead person. It is important to keep in mind that even the terms used for the wake and the funeral may vary according to religious and cultural beliefs. What is called a wake in many North American religions may be called a viewing or Home going by others. Customs for disposal of the body after death vary widely. Muslims have specific rituals for washing, dressing, and positioning the body. In traditional Judaism, cosmetic restoration is discouraged, as is any attempt to hasten or retard decomposition by artificial means. As part of their lifelong preparation for death, Amish women sew white burial garments for themselves and for their family members (Wenger, 1991). For the viewing and burial, faithful Mormons are dressed in white temple garments. Burial clothes and other religious or cultural symbols may be important items for the funeral ritual. If such items are present, you should ensure that they are taken by the family or sent to the funeral home. Believing that the spirit or ghost of the deceased person is contaminated, some Navajos are afraid to touch the body after death. In preparation for burial, the body is dressed in fine apparel, adorned with expensive jewelry and money, and wrapped in new blankets. After death, some Navajos believe that the structure in which the person died must be burned. There are specific members of the culture whose role is to prepare the body and who must be ritually cleansed after contact with the dead. Funeral arrangements vary from short, simple rituals to long, elaborate displays. Among the Amish, family members, neighbors, and friends are relied on for a short, quiet ceremony. Many Jewish families use unadorned coffins and stress simplicity in burial services. Some Jews fly the body to Jerusalem for burial in ground considered to be holy. egardless of economic considerations, some groups believe in lavish and costly funerals.

Religious Trends in the United States and Canada The United States and Canada are cosmopolitan nations to which all of the major and many of the minor faiths of Europe and other parts of the globe have been transplanted. Religious identification among people from different racial and ethnic groups is important because religion and culture are interwoven. Table 13-1 details the statistical breakdown of major religious affiliations of the United States and Canada (Figure 13-2). Selected religious groups and their respective memberships numbers in the United States and Canada are identified in Table 13-2. As discussed, a wide range of beliefs frequently exists within religions —a factor that adds complexity. Some religions have a designated spokesperson or leader who articulates, interprets, and applies theological tenets to daily life experiences, including those of health and illness. These leaders include Jewish rabbis, Catholic priests, and Lutheran ministers. Some religions rely more heavily on individual conscience, whereas others entrust decisions to a group of individuals, or to a single person vested with ultimate authority within their religious tradition.

Although it is impossible to address the health-related beliefs and practices of any religion adequately, this chapter offers a brief overview of selected groups. Some of the world’s religions fall into major branches or divisions, such as Vaishnavite and Shaivite Hinduism; Theravada and Mahayana Buddhism; Orthodox, Reform, and Conservative Judaism; Roman Catholic, Orthodox, and Protestant …